Pleural Effusion Of Unknown Etiology Research Articles

The Assessment of Pleural Effusion Using CT Pulmonary Angiography-A Review

Background: Pleural effusion is a common clinical presentation with various etiologies, including pulmonary embolism (PE), which remains underdiagnosed. The association between PE and pleural effusion, particularly the exudative type, necessitates a thorough understanding of the diagnostic role of computed tomography pulmonary angiography (CTPA). Objective: This review aims to elucidate the prevalence and characteristics of pleural effusions in PE patients and to evaluate the effectiveness of CTPA in the diagnosis of unilateral pleural effusions of unknown etiology. Methods: A systematic search across databases such as Google Scholar, PubMed, and NCBI yielded 39 articles, from which 20 met the inclusion criteria focused on the diagnostic utility of CTPA for unilateral pleural effusion. Studies were appraised for relevance to PE and pleural effusion, methodological rigor, and contribution to the field. Results: The review revealed that pleural effusions associated with PE typically present modestly and peak around the third day post-embolism. Persistent or late-onset effusions may suggest recurrent embolism or other pathologies. Contrast-enhanced CT demonstrated variable sensitivity and specificity in detecting malignant pleural effusions, suggesting the need for cautious interpretation and possible further invasive investigation. Conclusion: CTPA plays a critical role in the evaluation of pleural effusion, especially when PE is suspected. An integrated diagnostic approach, including pleural-phase thoracic CT, is recommended for patients with suspected malignant pleural effusions to improve clinical outcomes.

Medical thoracoscopy – Diagnostics of pleural effusion with indefinite etiology

Introduction: Pleural effusion occurs when extra fluid accumulates in the pleural space of the body. Pleural effusion is a symptom of underlying pathology caused by lung, pleural, and systemic diseases. In approximately 75% of patients, cytobiochemical and microbiological investigation of pleural fluid can provide an etiological diagnosis. Despite thoracentesis diagnostics and its concerned workup, the root cause remains unidentified. Despite primary tests, medical thorocoscopy plays an important role in undiagnosed pleural effusion. This study is planned in order to appraise as to what would be the diagnostic yield on implementing medical thoracoscopy in a tertiary care centre where patients were being treated for pleural effusion of unknown etiology. Methodology: From June 2021 to June 2022, Saveetha Medical College and Hospital in Thandalam, Kanchipuram, initiated a prospective, interventional, and non-randomised study. Our institution conducted a study on pleural effusion cases that were not diagnosed following the initial biochemical and cytological analysis of their respective pleural fluids. Results: This study included 53 patients with pleural effusion. 42 patients(79.25%) had definitive diagnosis and 11 patients(20.75%) had inconclusive histopathological report. It was noted that 30 (56.6%) patients with definitive diagnosis had cancer, 10 (18.9%) had tuberculosis, and 2 (3.8%) had empyema. In our investigation, the diagnostic yield on implementing medical thoracoscopy was 79.25%. The overall sensitivity in our study was 89.36%, with specificity at 100%, positive predictive assessment at 100%, and negative predictive assessment at 54.5%. Conclusion: Medical thoracoscopy is a minimally invasive, well-tolerated, and safe process that aids in the accurate identification of pleural effusion of unknown etiology. It also allows for the provision of therapeutic approaches such as pleurodesis and adhesiolysis. As a consequence, patients having pleural effusion in which the etiology is not known should opt for medical thoracoscopy.

Scope of medical rigid thoracoscopy in patients with pleural effusion of unknown etiology: A prospective single center study

Background: Pleural diseases commonly encountered are pleural effusion, pneumothorax, pleural wall thickening, and pleural mass. Medical thoracoscopy is a minimally invasive procedure that allows diagnostic and therapeutic intervention. The medical diagnostic thoracoscopy in local anesthesia is a simple, low-cost investigation with relatively high diagnostic accuracy, no mortality, and low morbidity. A diagnosis of pleural tuberculosis (TB) could be achieved in 99% of patients as against 51% using closed pleural biopsy. Aims and Objectives: Assessment of the role of medical rigid thoracoscopy in patients with pleural effusion of unknown etiology in a tertiary health care setup. The primary objectives of the study were to evaluate the diagnostic yield of medical thoracoscopy in pleural effusion of unknown etiology. Materials and Methods: The study duration/time frame to address the study: November 2017–February 2019 sample size with Justification Sample size: Minimum 31 patients. It was a prospective observational study. All patients admitted in hospital/daycare at LHRC presenting with pleural effusion with unknown etiology. All patients had a medical thoracoscopy, and samples were sent for microbiological and histological analysis. Clinical, thoracoscopic results and histopathological data of the patients were collected prospectively and analyzed. Results: In this study, 28 patients out of 31 patients were diagnosed. The diagnostic yield of thoracoscopic pleural biopsy was 90.3% Out of 31 patients, the most common complication found was chest pain 48.4% (15/31), followed by 09.7% (03/31) of the cases had complications such as surgical emphysema, postoperative fever, and bleeding. There were no complications in 32.2% (10/31) patients. Conclusion: Medical thoracoscopy is a noble procedure that helps the pulmonologist/surgeon to inspect the pleural cavity. It is a safe and effective diagnostic as well as a therapeutic tool with a high diagnostic yield. The most common differentials of undiagnosed pleural effusion cases are TB and malignancy.

Precut technique using an injection needle: A retrospective study on a new ancillary procedure for pleural biopsy.

The effectiveness of thoracoscopic biopsy as a diagnostic method for pleural diseases has been reported; however, obtaining a sufficient specimen size is sometimes difficult. Therefore, an ancillary technique, the precut technique using an injection needle, was devised to address this problem. This study aimed to evaluate the effectiveness and safety of the novel precut technique in patients with undiagnosed pleural effusion.This retrospective study included 22 patients who underwent pleural biopsy using the precut technique to examine exudative pleural effusion of unknown etiology. Thoracoscopy was performed under local anesthesia. The biopsy procedure was performed as follows: a needle was inserted into the pleura around the lesion using a semiflexible thoracoscope; the needle was positioned to make an incision in the pleura while injecting 1% lidocaine with epinephrine and lifting the pleura from the fascia; 2 or 3 precut incision lines were arranged in a triangle; and the specimen was obtained from the parietal pleura using forceps or a cryoprobe. Patient data including age, number of biopsies, biopsy specimen size, pathological and final diagnosis, and postoperative complications were examined.All patients were male with an average age of 74 years. Pleural effusion was found on the right and left sides in 16 and 6 patients, respectively. The average major axis of the biopsy specimens was 18 mm (range, 10–30 mm), which was sufficient to establish a pathological diagnosis. Only 1 patient experienced minor temporal bleeding as a complication.The precut technique enabled the procurement of specimens sufficient in size for pleural biopsy.

Pleural pathology in HIV-infected patients: features of morphological diagnostics

Background. The progression of HIV infection is accompanied by the development of opportunistic diseases, including pleural effusions of various origins. Morphological examination of pleura tissue in cases of pleural effusion serves as the basis for establishing the etiology of the pathological process and, therefore, the final clinical diagnosis. Objective – analysis of results of morphological diagnostics of pleura lesions in HIV-infected patients in comparison with other laboratory tests and clinical diagnosis. Methods. 103 cases of pleurisy of various origins were studied. Pleural biopsies were obtained by various types of minimally invasive diagnostic interventions with subsequent morphological examination. Results were compared with the available data of microbiological and molecular genetic studies of pleural biopsies. Results. At the time of hospitalization the preliminary clinical diagnosis was pleurisy of unknown etiology in 96,1 % of cases. A combined disease was diagnosed – hepatitis C in a third of all observations according to the results of laboratory tests. Due to routine staining with hematoxylin and eosin, tuberculosis lesions of the pleura were diagnosed in 59,2 %, the second most frequent was the diagnosis of nonspecific pleurisy, 20,4 %. According to the duration of the process, acute pleural tuberculosis was established in 19,7 % of cases, the subacute form of tuberculosis pleurisy – in 54,1 % of cases, and chronic pleural tuberculosis was established in 22,9 % of cases. In 17,5 % of cases, in order to clarify the etiology of pleurisy, additional histochemical staining for infectious agents was performed. The results of microbiological and molecular genetic studies were established in 76,7 % of cases. The greatest number of M. tuberculosis detection was obtained during the culture study of the biopsy material and exudates. When comparing the final clinical diagnosis and the level of CD4 cells in peripheral blood, it was found that in most cases (74,5 %) pleural effusions developed at low counts of CD4 cells, less than 350/l. Conclusion. Tuberculosis predominates in the etiological structure of pleural effusions in patients with HIV infection. Pleural tuberculosis can be the main secondary disease or be combined with pulmonary tuberculosis. In second place in terms of frequency of occurrence, nonspecific pleurisy was diagnosed as a complication of the main secondary disease. Pleural effusions develop when CD4 cell counts are low. Morphological diagnostics of pleural lesions is the main research method in the diagnostic algorithm of cases of pleural effusions of unknown etiology against the background of HIV infection.

S2230 Atypical Endoscopic Appearance of Duodenal Mucosa in Whipple’s Disease: An Incidental Finding in an African American Patient

Introduction: Whipple’s disease (WD) is an extremely rare disorder of European white males with an annual incidence reported as less than one case per million. It is a chronic infectious multisystem disorder caused by the bacterium Tropheryma whipplei. Esophagogastroduodenoscopy (EGD) is the gold standard for diagnosis which typically reveals alternating yellow shaggy and eroded erythematous small bowel mucosa. We report a biopsy-proven case of WD in an African American male with atypical endoscopic appearance of the duodenum revealing diffusely dispersed prominent white spots, swollen folds and mucosal nodularity. Case Description/Methods: A 45-year-old male presented with a 6-month history of watery diarrhea, anorexia, unintentional weight loss and exertional dyspnea. He had a history of seizures, recurrent pleural effusion of unknown etiology, vitamin D deficiency and iron deficiency anemia. Physical exam was remarkable for an underweight patient with pale conjunctivae, mild diffuse abdominal tenderness and decreased right sided breath sounds. Vital signs were stable. Patient was in no acute distress. Labs include Hb 10 mg/dL, albumin 2.1 g/dL, vitamin D 13.6 ng/mL, zinc 44 mcg/dL, ESR 45 mm and CRP 107 mg/dL. Stool was negative for ova/parasite, bacterial culture, C.difficile and AFB. Workup for celiac disease and neuroendocrine tumors also reported negative. CT imaging revealed gastric antral wall thickening, abdominal/pelvic ascites and right pleural effusion. Given these non-specific findings, malignancy workup was warranted. EGD revealed an unusual gross appearance of the second portion of duodenum with diffusely dispersed prominent white spots, swollen folds and mucosal nodularity (Fig. 1-a). Biopsy was consistent with WD (Fig. 1-b,c). Colonic and pleural biopsies were negative for malignancy. The patient showed significant clinical response to induction therapy with ceftriaxone followed by maintenance phase with TMP-SMX. Follow up is scheduled to assess endoscopic response to antibiotic therapy. Discussion: WD is a challenging diagnosis due to a constellation of symptoms that mimic other disorders. Whitish discoloration with mucosal nodularity is a rare but more specific endoscopic finding for WD, as reported in our case. Biopsy is required to confirm the diagnosis. This case is reported to draw gastroenterologists’ attention towards atypical endoscopic findings of WD. Early recognition of this debilitating and potentially fatal illness is the key before commencement of prolonged antibiotic therapy.Figure 1.: A. CT Chest with Pneumomediastinum B. Upper Endoscopy With Erythematous Posterior Oropharynx and an Extrinsic, Longitudinal Bulge in the Proximal Esophagus C. Intraoperative Photograph During Thoracotomy.

Diagnostic accuracy of semirigid thoracoscopy in exudative pleural effusions and relationship of thoracoscopic findings with probability of malignant diagnosis.

Semirigid thoracoscopy is increasingly becoming the procedure of choice for evaluation of undiagnosed exudative pleural effusions. Few studies have reported relationship of thoracoscopic appearances of pleural abnormalities and etiological diagnoses. We aimed our study to assess the diagnostic utility and safety of semirigid thoracoscopy for evaluation of patients with undiagnosed exudative pleural effusion. Further, we also pursued to find any relation of various thoracoscopic findings with the final diagnosis. We prospectively enrolled hospitalized patients with undiagnosed exudative pleural effusion who underwent semirigid thoracoscopy. Demographic, clinical and laboratory data along with data on thoracoscopic appearance of various pleural abnormalities and histopathological diagnosis of pleural biopsy specimens were collected and analysed. Semirigid thoracoscopy was diagnostic in 46 (N=55) patients (83.64%). Malignancy was diagnosed in 31 patients (56.36%), of which adenocarcinoma was the most common histopathological diagnosis (45.16%). Sensitivity, specificity, PPV, NPV LR+ and LR- of thoracoscopy were 93.87%, 100%, 100%, 66.67%, 40.30 and 0.06, respectively. Pleural nodules, masses and hemorrhagic pleural fluid significantly increased the diagnosis yield of malignancy [OR= 37.16 (95%CI = 3.61-382.65), =0.002]. The procedure related complications were mild and transient. Post- procedural pain (20%) was most commonly reported followed by dry cough (18.18%), sub-cutaneous emphysema (7.27%) and anaesthesia related complication (1.82%). Semirigid thoracoscopy is simple, safe and effective procedure in diagnosing exudative pleural effusion of unknown etiology with high diagnostic accuracy and minor procedure related complications. The likelihood of diagnosing malignancy is high if combination of pleural nodules, masses and hemorrhagic pleural fluid is present.

Pleuroscopy Early Experience in the Exudative Pleural Effusion of Unknown Etiology

Background: Pleuroscopy (medical thoracoscopy) is a minimally invasive procedure to inspect and perform a biopsy of the pleural space as well as to perform therapeutic interventions; pleural fluid drainage and pleurodesis. Material and Methods: In a retrospective study in Kasra Hospital, Tehran,Iran, the patients with exudative pleural effusion of unknown etiology who underwent pleuroscopy, were evaluated. These patients had negative smears and cultures for infective agents. Also, the cytological review was negative for malignancy. Results: 62 patients had undergone pleuroscopy, of which 29 (46.7) were men. After the final evaluation, 47 patients (75.8%) had a definite pathologic diagnosis, of which 39 patients (82.9%) had cancer. Through these 39 cases, 18 cases (46.1%) had a history of the previously confirmed cancer, in which pleural pathology was consistent with the initial diagnosis. In 21 cases (53.9%), metastatic cancers were detected without a previous history. From a total of 47 cases with definite pathologic diagnosis, 8 cases (17%) had histopathologic evidence of granulomatous lesions consistent with tuberculosis, and 15 patients (24%) showed non-specific inflammatory lesions. There was no morbidity and mortality among these patients. Discussion: Considering that pleuroscopy is a safe procedure with high diagnostic accuracy, malignancy is the most common finding in the exudative pleural effusion of unknown etiology, which increases the importance of this procedure in these cases to prevent wasting time and smear-negative anti-TB treatment.

Medical Thoracoscopy, Computed Tomography-guided Biopsy, and Ultrasound-guided Biopsy for Malignant Pleural Mesothelioma: A Systematic Review.

Although surgical thoracoscopy is recommended in the diagnosis of malignant pleural mesothelioma (MPM), the invasiveness of this procedure is of strong concern. Our review aimed to evaluate the accuracies of medical thoracoscopy (MT), computed tomography (CT)-guided biopsy, and ultrasound (US)-guided biopsy in the diagnosis of MPM among patients with pleural effusion. We searched the MEDLINE, Embase, Central, and International Clinical Trials Registry Platform databases for studies evaluating the diagnostic accuracy of at least one of the biopsy procedures among patients with pleural effusion of unknown aetiology who had undergone thoracentesis and/or blind biopsy. A hierarchical summary receiver operating curve was created for MT. Following full-text screening, 15 studies were included. MT studies had a high risk of bias and low applicability concern; however, hierarchical summary receiver operating curve revealed that MT had a high sensitivity. MT might be a useful rule-in test for guiding the use of more invasive diagnostic procedures.

MALIGNANT MESOTHELIOMA AND GERMLINE HETEROZYGOUS BAP1 MUTATION IN A YOUNG WOMAN PRESENTING WITH RECURRENT PLEURAL EFFUSIONS AND WORSENING PNEUMOTHORAX AFTER TALC PLEURODESIS

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Germline BAP1 mutations are associated with a pattern of hereditary malignancies, namely uveal and cutaneous melanoma, malignant mesothelioma (MM), and renal cell carcinoma. We present a rare case of a young woman who was diagnosed with malignant pleural and peritoneal mesothelioma. CASE PRESENTATION: A 23 year-old woman with no known medical conditions or exposure to asbestos was referred to medical oncology after completing a video-assisted thoracoscopic surgery (VATS) followed by talc pleurodesis for recurrent pleural effusions of unknown etiology. Initial pleural fluid studies showed total protein 4.5 g/dL and LDH 150 U/L. Pleural fluid contained clusters of atypical mesothelial cells surrounded by inflammation suggestive of reactive mesothelial hyperplasia. VATS found abnormal reticulated surfaces and a white plaque-like tissue at the apex. Pleural biopsies showed atypical mesothelial proliferation suspicious for MM in a background of reactive changes, but ultimately results were considered non-diagnostic. Due to inconclusive pathology we recommended further evaluation with diagnostic laparoscopy because her CT scans also showed small volume ascites and pelvic fluid. Studding was noted on peritoneum, bowel, pelvic tissues, and omentum, and biopsies showed markedly atypical proliferation of epithelioid cells forming glandular and tubulopapillary structures with disorganized growth and focal invasion into adjacent adipose tissue. Immunostains of tumor cells were consistent with mesothelial differentiation. BAP-1 immunohistochemistry showed loss of expression only in tumor cells. Collectively these features supported a diagnosis of MM of epithelioid type. Peripheral blood testing for BAP1 tumor predisposition syndrome (BAP1-TPDS) was positive for a heterozygous germline BAP1 mutation, c.2050 C>T, p.Gln684* (Pilarski et al. 2013, Haugh et al. 2017). Staging scans prior to chemotherapy showed interval development of a pneumothorax in the right lung months after her talc pleurodesis. She was treated with cisplatin, pemetrexed, and bevacizumab with subsequent improvement of her pneumothorax. DISCUSSION: Our case report showed the clinical features of a patient with MM from BAP1-TPDS. Loss of BAP1 expression can help distinguish MM from reactive mesothelial cells (Cigognetti et al. 2015). Progression of her disease after having a talc pleurodesis manifested radiographically as a worsening pneumothorax, and chemotherapy was able to reverse this process. CONCLUSIONS: Unexplained pleural effusions or pleural or peritoneal biopsies showing atypical mesothelial cells should have immunohistochemistry testing for loss of BAP1 expression to evaluate for MM. MM due to BAP1-TPDS is responsive chemotherapy. Young MM patients without risk factors for MM should have germline testing for BAP1-TPDS. Reference #1: Pilarski, Robert, et al. “Expanding the Clinical Phenotype of hereditaryBAP1cancer Predisposition Syndrome, Reporting Three New Cases.” Genes, Chromosomes and Cancer, vol. 53, no. 2, 15 Nov. 2013, pp. 177–182., doi:10.1002/gcc.22129. Reference #2: Haugh, Alexandra M., et al. “Genotypic and Phenotypic Features of BAP1 Cancer Syndrome.” JAMA Dermatology, vol. 153, no. 10, 9 Aug. 2017, p. 999-1006., doi:10.1001/jamadermatol.2017.2330. Reference #3: Cigognetti, Marta, et al. “BAP1 (BRCA1-Associated Protein 1) Is a Highly Specific Marker for Differentiating Mesothelioma from Reactive Mesothelial Proliferations.” Modern Pathology, vol. 28, no. 8, 29 May 2015, pp. 1043–1057., doi:10.1038/modpathol.2015.65. DISCLOSURES: Speaker/Speaker's Bureau relationship with Daiichi Sankyo/AstraZeneca Please note: $1-$1000 Added 03/18/2020 by Blakely Kute, source=Web Response, value=Honoraria No relevant relationships by Eric Luk, source=Web Response

Bilateral pleural effusion of pancreatic etiology: A rare case report

Pleural effusions occuring as a result of acute or chronic pancreatitis are usually transient, short lived and are easily curable if the diagnosis is identified. It is mostly left sided and less likely right sided and very rarely bilateral. We are hereby reporting a case of a 38 year old male patient who was a chronic alcoholic who was symptomatic for left sided pleural effusion. Pleural fluid examination revealed high amylase levels suggesting a pancreatic etiology for the effusion. After 1 week of hospitalisation, the patient developed right sided effusion in addition to the left sided effusion. Unilateral or bilateral exudative pleural effusion of unknown etiology and elevated pleural fluid amylase should be suspected as pleural effusions with an underlying pancreatic pathology. The pathology in the pancreas was confirmed with the radiological investigations supportive of pancreatitis. Pancreatitis not only develop haemorrhagic pleural effusion, it also produce bilateral pleural effusion. Elevated amylase levels in pleural fluid is suggestive of pancreatic aetiology. Timely surgical intervention like E will reduce the pleural effusion and improves survival.

La thoracoscopie médicale en pratique pneumologique : expérience du CHU de Liège

The incidence of pleural disease continues to increase worldwide. Medical thoracoscopy remains the standard method for exploration of the pleural cavity. We report the retrospective evaluation, the efficacy and the observed complications in 1024 medical thoracoscopies undertaken in the University Hospital of Liège between 2000 and 2017. In total, 100 pneumothoraces and 400 benign and 501 malignant pleural diseases were identified. The main indication for thoracoscopy remains the diagnosis of an exudative, lymphocytic pleural effusion of unknown aetiology after thoracocentesis. The diagnostic sensibility of thoracoscopy was 99.2% in distinguishing benign from malignant pleural disease. Talc pleurodesis was performed in 69.5% of the total population and in 66.1% of pleural effusions or thickening. Failure of pleurodesis was observed in 11% of the patients with recurrent pneumothorax and in 7.8% of neoplastic pleural effusion. We report a mortality of 0.6% in the 30 days post procedure, long duration of drainage in 8.3% and serious complications in 4.7%. In 22/1024 (2.1%) thoracoscopic evaluation was not feasible because of dense pleural fibrosis. Medical thoracoscopy is a safe, well-tolerated procedure with high accuracy in the diagnostic and therapeutic management of pleural disease.

The use of light's criteria in hospitalized children with a pleural effusion of unknown etiology.

Pleural effusions are common in pediatrics. When the etiology of a pleural effusion remains unknown, adult literature recommends the use of Light's criteria to differentiate a transudate from an exudate. Pediatricians may rely on adult literature for the diagnostic management of pleural effusions as Light's criteria has not been validated in children. The purpose of this study was to review the use of Light's criteria in hospitalized children with a pleural effusion of unknown etiology. Retrospective review was performed on children hospitalized with a pleural effusion requiring chest tube placement or thoracentesis between January 1, 2016 to January 1, 2017 at Children's Hospital Colorado. Charts were reviewed for primary team, use of Light's criteria, pleural effusion diagnosis, and 30-day recurrence of repeat intervention or fluid analysis. Sixty-eight patients were hospitalized with a pleural effusion of unknown etiology requiring intervention. Only 16 pleural effusions (24%) were classified using Light's criteria. In those patients for whom Light's criteria was used, a diagnosis or change in management occurred in 10 of 16 patients (63%). Pleural effusions were most common on the cardiology service (26/68). Use of Light's criteria was most frequent on the oncology service (7/8). Thirty-day need for repeat intervention was lower in those with Light's criteria (13%) compared to those without (27%). Light's criteria were utilized infrequently in hospitalized children with a pleural effusion of unknown etiology at a single institution. There was considerable practice variation among provider teams. When utilized, Light's criteria assisted in making a diagnosis or changing management in many patients, and may lead to a reduction in 30-day recurrence requiring repeat intervention.

Diagnostic value of medical thoracoscopy in malignant pleural effusion induced by non-Hodgkin's lymphoma.

Malignant pleural effusion (MPE) appears in up to 20% of patients with non-Hodgkin's lymphoma (NHL). The present study aimed to assess the efficacy of medical thoracoscopy (MT) in the diagnosis of patients with MPE induced by NHL. Between July 2005 and June 2014, 833 patients with pleural effusions of unknown etiology underwent MT in Beijing Chaoyang Hospital (Beijing, China), where diagnostic thoracocentesis or/and blind pleural biopsy had failed to yield an answer. Demographic, radiographic, thoracoscopic, histological and immunophenotyping data of 10 NHL patients with MPE were then retrospectively analyzed. Under medical thoracoscopy, pleural nodules (in n=6 patients), hyperemia (n=5), plaque-like lesions (n=4), pleural thickening (n=3), cellulose (n=3), ulcer (n=2), adhesion (n=2), and scattered hemorrhagic spots (n=1) were observed on the surface of parietal pleura. Histopathological and immunohistochemical analysis of pleural biopsy samples led to a correct diagnosis of B-cell NHL in 7 patients and T-lymphoblastic NHL in 2 patients. Data from the present study demonstrated that pleural biopsy through MT achieved a definite diagnosis of NHL in 9 out of 10 (90%) patients with MPE induced by NHL. Therefore, MT is a useful method for diagnosing MPE induced by NHL.

Predicting Malignant and Paramalignant Pleural Effusions by Combining Clinical, Radiological and Pleural Fluid Analytical Parameters.

The usefulness of clinical, radiological and pleural fluid analytical parameters for diagnosing malignant and paramalignant pleural effusion is not clearly stated. Hence this study aimed to identify possible predictor variables of diagnosing malignancy in pleural effusion of unknown aetiology. Clinical, radiological and pleural fluid analytical parameters were obtained from consecutive patients who had suffered pleural effusion of unknown aetiology. They were classified into three groups according to their final diagnosis: malignant, paramalignant and benign pleural effusion. The CHAID (Chi-square automatic interaction detector) methodology was used to estimate the implication of the clinical, radiological and analytical variables in daily practice through decision trees. Of 71 patients, malignant (n=31), paramalignant (n=15) and benign (n=25), smoking habit, dyspnoea, weight loss, radiological characteristics (mass, node, adenopathies and pleural thickening) and pleural fluid analytical parameters (pH and glucose) distinguished malignant and paramalignant pleural effusions (all with a p<0.05). Decision tree 1 classified 77.8% of malignant and paramalignant pleural effusions in step 2. Decision tree 2 classified 83.3% of malignant pleural effusions in step 2, 73.3% of paramalignant pleural effusions and 91.7% of benign ones. The data herein suggest that the identified predictor values applied to tree diagrams, which required no extraordinary measures, have a higher rate of correct identification of malignant, paramalignant and benign effusions when compared to techniques available today and proved most useful for usual clinical practice. Future studies are still needed to further improve the classification of patients.

Fatal pleural mesothelioma in Japan (2003-2008): evaluation of computed tomography findings.

The purpose of this study was to clarify the characteristic findings of mesothelioma at the time of diagnosis, and determine precautions and guidelines for diagnosing mesothelioma early in imaging studies. Overall, 327 patients with pleural mesothelioma were selected from 6030 patients who died of mesothelioma between 2003 and 2008 in Japan. Their imaging findings were examined retrospectively. Plaques were found in 35% of computed tomography (CT) scans. Asbestosis, diffuse pleural thickening, and rounded atelectasis were found in only seven (2%), five (2%), and two cases (1%), respectively. Pleural thickening findings on CT scans were classified into four stages: no irregularity, mild irregularity, high irregularity, and mass formation. Overall, 18% of cases did not show a clear irregularity. Localized thickening was observed in the mediastinal (77%) and basal (76%) pleura and in the interlobar fissure (49%). Eight percent of cases did not have any thickening in these three areas. Upon examination of the CT scans at diagnosis, 18% of mesothelioma cases did not show a clear irregularity. When diagnosing pleural effusion of unknown etiology, it is necessary to consider the possibility of mesothelioma even when no plaque and pleural irregularity are observed.

Efficacy and Safety of Diagnostic Thoracoscopy in Undiagnosed Pleural Effusions

Background: The differential diagnosis of pleural effusions can present a considerable challenge, and the etiology of pleural effusions varies depending on the population studied. Objective: This study aimed to assess the efficacy and safety of medical thoracoscopy in the diagnosis of patients with undiagnosed pleural effusions in a Chinese population. Methods: Between July 2005 and June 2014, medical thoracoscopy (MT) using the semirigid instrument was performed in 833 patients with pleural effusions of unknown etiology in our Institute, where diagnostic thoracocentesis or/and blind pleural biopsy had failed to yield an answer. Demographic, radiographic, procedural, and histological data were recorded and analyzed. Results: During this 9-year study, satisfactory pleural biopsy samples were obtained in 833 patients, and MT revealed malignant pleural effusion in 342 (41.1%) patients, benign pleural effusion in 429 (51.5%) patients, and 62 (7.4%) patients could not get definite diagnoses. The overall diagnostic efficiency of MT was 92.6% (771/833). After MT, the only severe complication was empyema, seen in 3 patients (0.4%). The most common minor complication was transient chest pain (44.1%) from the indwelling chest tube. Conclusions: MT is an effective and safe procedure for diagnosing pleural effusions of undetermined causes. In areas with high tuberculosis prevalence, MT should be particularly helpful in the differential diagnosis of tuberculous pleural effusion.

A 63-year-old man with a recurrent right-sided pleural effusion

JPC : A 63-year-old Caucasian man was seen in clinic having been referred by his general practitioner with a 10 -week history of progressive exertional dyspnoea, associated with dry cough...

Effectiveness and safety of diagnostic flexi-rigid thoracoscopy in differentiating exudative pleural effusion of unknown etiology: a retrospective study of 215 patients.

The aim of this study was to evaluate the effectiveness and safety of diagnostic flexi-rigid thoracoscopy in differentiating exudative pleural effusion of unknown etiology. A total of 215 patients with undiagnosed exudative pleural effusion were consecutively recruited between January 2011 and February 2013. Thoracoscopy was carried out under local anesthesia, and multisite pleural biopsies were performed using a flexi-rigid thoracoscope. The tolerance of the patients, surgical complications and postoperative pathological diagnosis rate were used to evaluate the effectiveness and safety of the thoracoscopy procedures. All patients, Karnofsky performance status (KPS) >70, could tolerate both the thoracoscopic surgery and pleural biopsy; there were no severe complications. Thoracoscopic findings included pleural hyperaemia, fibrinous adhesion, nodular bulge and fester. The pathological biopsy confirmed diagnoses of malignant tumor (97 cases), tuberculous pleuritis (91 cases), tuberculous empyema (one case), pulmonary schistosomiasis (one case) and unknown etiology (25 cases). The total diagnosis rate was 88.4%. Subcutaneous emphysema occurred in ten cases and fever in six cases, all of which recovered completely with conservative treatment. Flexi-rigid thoracoscopy had a high diagnosis rate, differentiating exudative pleural effusion of unknown etiology with satisfactory effectiveness and safety. There was high degree of relationship between thoracoscopic appearance and primary disease or tumor classification.

Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: Impact on patient management

ObjectiveTo evaluate the impact of coronary CT angiography (coronary CTA) or “triple-rule-out” CT angiography (TRO-CTA) on patient management in the work-up of patients with acute chest pain and an intermediate cardiac risk profile. Materials and methods100 patients with acute chest pain and an intermediate cardiac risk for acute coronary syndrome (ACS) underwent coronary CTA or TRO-CTA for the evaluation of chest pain. Patients with a high and low cardiac risk profile were not included in this study. All patients with significant coronary stenosis >50% on coronary CTA underwent invasive coronary catheterization (ICC). Important other pathological findings were recorded. All patients had a 90-day follow-up period for major adverse cardiac events (MACE). ResultsBased on a negative coronary CTA 60 of 100 patients were discharged on the same day. None of the discharged patients showed MACE during the 90-day follow-up. Coronary CTA revealed a coronary stenosis >50% in 19 of 100 patients. ICC confirmed significant coronary stenosis in 17/19 patients. Among the 17 true positive patients, 9 underwent percutaneous coronary intervention with stent implantation, 7 were received intensified medical therapy, and 1 patient underwent coronary artery bypass surgery.A TRO-CTA protocol was performed in 36/100 patients due to elevated d-dimer levels. Pulmonary embolism was present in 5 patients, pleural effusion of unknown etiology in 3 patients, severe right ventricular dysfunction with pericardial effusion in 1 patient, and an incidental bronchial carcinoma was diagnosed in 1 patient. ConclusionCoronary CTA and TRO-CTA allow a rapid and safe discharge in the majority of patients presenting with acute chest pain and an intermediate risk for ACS while at the same time identifies those with significant coronary artery stenosis.